History In order to take a comprehensive record of constipation symptoms, a multifaceted questionnaire is recommended. The questions must be clear and emphasize that the patient is in great pain. Complaints may include decreased frequency of bowel movements, difficulty with bowel movements (straining, hard stools, incomplete bowel movements), symptoms that support bowel stress syndrome (bloating, abdominal pain) or a combination of all these symptoms. When constipation occurs in the elderly, the symptoms may be chronic or recent. Recent onset of constipation, especially within the last two years, is often secondary to other causes, and the exclusion of the colon itself and extracolonic disease, including malignant disease, must be taken into account. Conversely, in most patients constipation is caused by congenital factors, which is a lifelong symptom, such as congenital megacolon or meningeal bulge. Typical clinical manifestations of obstructive bowel movements include straining, a sensation of falling and incomplete bowel movements, often requiring suppositories, enemas or finger assistance. It is important to ask the patient if he/she requires other methods of bowel movement. Vaginal fingering suggests rectal distention in view of massage of the lateral anal wall to support weak rectal contractility. Patients with hernia of the utero-rectal fossa may report probing past the toilet seat gasket indicating that the patient is trying to tilt forward an intestinal hernia outside the rectum. In fact, patients with sigmoid hernias may report the need to compress the lower abdomen in order to defecate. Remember that any mechanoreceptor pressure adjacent to the rectal organs can cause the patient to feel an urge to defecate. These patients usually have a history of previous treatment for anorectal disorders associated with straining to defecate, such as rectal prolapse, descending perineal syndrome, isolated rectal ulcer syndrome, rectoanal condyloma, or prolapse. The Rome criteria are intended to suggest a diagnostic criterion for constipation, but not to assess its purpose. Different scoring systems have been developed in order to consistently assess the severity of constipation. The score is based on 8 parameters, including frequency of defecation, difficulty or pain in defecation, completeness of defecation, abdominal pain, minutes required for each defecation, mode of assisted defecation (laxative, finger or enema), number of unsuccessful defecations per 24 hours, and interval of constipation (years). According to the questionnaire, scores ranged from 0 to 30, with 0 being normal and 30 being severely constipated (Table 1). A scoring system corrected for objective physiological findings is proposed based on the authors’ experience with a study of 232 patients. The additional proposed instrument includes 3 sub-symptoms out of 12: fecal, rectal and abdominal. It was shown to be intrinsically consistent, reproducible, well-founded, responsive to change and therefore suitable for assessing the effectiveness of constipation treatment. Recently, Knowles et al. proposed another symptom scoring questionnaire to clarify chronic constipation. This questionnaire consists of 11 questions, and in a study of 71 patients and 20 asymptomatic controls, Wexner found a significant positive correlation. Although there is now no significant difference in the items analyzing the main pathophysiology of clinical practice symptoms. At least two scoring systems have been proposed in order to consistently assess constipation severity. In a study comparing symptoms and physiology, Glia et al. evaluated rectoanal manometry, electromyography, colonic transit time measurements, and defecography in 134 patients with registered symptoms. In this study, three symptoms were not associated with a diagnosis of slow-transit constipation: decreased bowel frequency (<< span="">2 times per week), laxative dependence, and a lifetime history of constipation. Patients had pelvic floor abnormalities with high incidence of back pain and low incidence of normal bowel frequency, heartburn, and a history of anorectal surgery compared to those with normal pelvic floor function. These authors postulated that those symptoms are predictors of good bowel transmission function, but not as predictors of pelvic floor function in constipated patients. Koch et al. also questioned whether a detailed symptom analysis is helpful in identifying groups of people with the pathophysiology of chronic constipation. These authors studied 190 patients with chronic constipation by symptom assessment, measurement of transit time, rectal-anal manometry and defecography. They found a low specificity for chronic transmission constipation using only decreased frequency of defecation, which is of little value in defining chronic constipation. However, symptoms requiring straining to defecate had good sensitivity in defining chronic constipation (94%). The sensation of obstruction and finger digging into the S stool were very specific, but not sensitive to bowel disorders. The authors conclude that symptoms in patients with chronic constipation are not helpful in distinguishing sub-groups of the pathophysiology of chronic constipation. In a study of 108 constipated patients, Mertz et al. confirmed the presence of three basic subsets of symptoms: chronic transmission, bowel stress syndrome, and pelvic floor dysfunction. Moreover, they evaluated whether these subsets were consistent with differentiating chronic transmission studies from anorectal sensorimotor function (rectoanal manometry, rectoanal manometry, tests of rectal sensation). According to these authors, chronic transmission and intestinal stress syndrome are correlated with the expected physiology expected physiology. In contrast, pelvic floor dysfunction symptoms are not related to physiology. However, these authors did not include defecography in their study, which may have influenced their final diagnostic rate. For the evaluation of constipation, patients must be asked if they have previously experienced voiding or defecatory incontinence. Anal incontinence is usually not reported and in fact exists in many constipated patients who have symptoms related to muscle denervation of the sphincter and pelvis leading to chronic bowel straining. In this case, the questionnaire should assess the frequency and type of anal incontinence, as well as the impact on the patient’s quality of life. The main problem in managing patients with spinal cord injury is constipation. The mechanisms include lack of urge to defecate, inability to move the body, paralysis of abdominal and pelvic muscle movements and possible altered movements of the colon, rectum and anus. Loss of reflex feedback activity from the brain into the rectum-anus rectum is stimulated by dilation to excrete its contents autonomously, resulting in fecal impaction and incontinence.